Enhanced recovery after spine surgery: a systematic review · as surgery in the lumbar spine,...

NEUROSURGICAL

FOCUS Neurosurg Focus 46 (4):E3, 2019

EnhancEd recovery after surgery (ERAS) is a mul-tidisciplinary, multimodal approach to improving surgical outcomes by using subspecialty- and proce-

dure-specific evidence-based protocols in the care of surgi-cal patients.33 Peer-reviewed ERAS protocols are available for various surgical disciplines and procedures. Despite technical differences in these protocols, a common motif is present: minimization and improvement of the stress re-sponse. The proposed rationale suggests that by maintain-ing homeostasis, untoward effects such as postoperative catabolism, pain, and immune dysfunction can be attenu-ated.25,32,47 Components and workflow of a typical ERAS pathway are demonstrated in Fig. 1.

Although Fearon et al.13 became the first to formalize

such protocols, similar systematic approaches to periop-erative care were espoused as early as the 1990s. Initially described as “fast-track surgery” designed to expedite re-covery and decrease length of stay (LOS), ERAS has since evolved in both language and approach to focus on opti-mizing the perioperative experience of surgical patients.25 To date, ERAS has been implemented in various surgical specialties.4,5,7,22,30,38,41,45,49,57 As the earliest discipline to implement ERAS, colorectal surgery offers a substantial body of literature supporting its benefits.10 For example, a meta-analysis of 16 randomized controlled trials (RCTs) of patients undergoing colorectal surgery found a signifi-cant reduction of overall morbidity and LOS with use of an ERAS protocol.21

ABBREVIATIONS ACDF = anterior cervical discectomy and fusion; AD = accelerated discharge; AIS = adolescent idiopathic scoliosis; ERAS = enhanced recovery after surgery; ERSS = enhanced recovery after spine surgery; LOS = length of stay; PCA = patient-controlled analgesia; PSF = posterior spinal fusion; RCT = randomized con-trolled trial; TD = traditional discharge; TLIF = transforaminal lumbar interbody fusion.SUBMITTED December 1, 2018. ACCEPTED January 25, 2019.INCLUDE WHEN CITING DOI: 10.3171/2019.1.FOCUS18700.

Enhanced recovery after spine surgery: a systematic reviewMazin Elsarrag, MS, Sauson Soldozy, BA, Parantap Patel, BS, Pedro Norat, MD, Jennifer D. Sokolowski, MD, PhD, Min S. Park, MD, Petr Tvrdik, PhD, and M. Yashar S. Kalani, MD, PhD

Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia

OBJECTIVE Enhanced recovery after surgery (ERAS) is a multidimensional approach to improving the care of surgical patients using subspecialty- and procedure-specific evidence-based protocols. The literature provides evidence of the benefits of ERAS implementation, which include expedited functional recovery, decreased postoperative morbidity, re-duced costs, and improved subjective patient experience. Although extensively examined in other surgical areas, ERAS principles have been applied to spine surgery only in recent years. The authors examine studies investigating the appli-cation of ERAS programs to patients undergoing spine surgery.METHODS The authors conducted a systematic review of the PubMed and MEDLINE databases up to November 20, 2018.RESULTS Twenty full-text articles were included in the qualitative analysis. The majority of studies were retrospective reviews of nonrandomized data sets or qualitative investigations lacking formal control groups; there was 1 protocol for a future randomized controlled trial. Most studies demonstrated reduced lengths of stay and no increase in rates of read-missions or complications after introduction of an ERAS pathway.CONCLUSIONS These introductory studies demonstrate the potential of ERAS protocols, when applied to spine proce-dures, to reduce lengths of stay, accelerate return of function, minimize postoperative pain, and save costs.https://thejns.org/doi/abs/10.3171/2019.1.FOCUS18700KEYWORDS enhanced recovery after surgery; fast-track recovery; spine surgery; scoliosis; minimally invasive surgery; degenerative spine disease

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From a healthcare management perspective, ERAS demonstrates financial benefits as well.29 A meta-analysis of 10 RCTs consisting of patients undergoing noncolorec-tal abdominal surgery calculated a mean cost reduction of $5109.10 (p < 0.001) in the ERAS versus control groups, which was attributed to the combined effect of decreased LOS and no increase in postoperative readmission in ERAS groups.51 Furthermore, cost savings often surpass the initial ERAS implementation costs.28,29 Patients’ posi-tive experiences following an ERAS protocol also indicate subjective benefit.31 A study of 95 patients undergoing colorectal surgery observed an increased sense of readi-ness for discharge (41st to 99th percentile), satisfaction with pain control (43rd to 98th percentile), and likelihood of the patient recommending the hospital (32nd to 89th percen-tile) in the ERAS group compared to the control group.48

Given the apparent benefits of ERAS programs in other surgical disciplines, it is not surprising that its implemen-tation in spine surgery is becoming increasingly common. Wainwright et al.52 provided an excellent overview for re-covery barriers in the postoperative period with regard to spine surgery, citing that spinal procedures are associated with high amounts of pain, slow return of function, and prolonged hospital stays, among other complications. Al-

though they performed a wide literature review examin-ing the adoption of ERAS protocols in spine surgery, the majority of studies identified at the time examined only individual components of ERAS pathways rather than comprehensive programs. Nonetheless, the evidence they reviewed indicated that ERAS principles would likely expedite return to function and minimize postoperative morbidity.

The aim of this systematic review was to identify and examine studies investigating the application of formal ERAS programs to patients undergoing spine surgery.

MethodsA literature search using PubMed and MEDLINE data-

bases on November 20, 2018, was performed using the key-words listed below in combination with Boolean “AND” and “OR” phrases. Titles and abstracts were screened for relevance, and articles describing implementation of enhanced-recovery programs in the context of any spine surgery were included. Bibliographies of works included in the final qualitative synthesis were hand searched for additional relevant studies not found in the original search. Case reports, review articles, or other works without origi-

FIG. 1. Components and workflow of a typical ERAS pathway. Copyright American Association of Nurse Anesthetists. Published with permission.


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nal data and studies examining only multimodal analgesia or comparing the efficacy of various analgesic medica-tions were excluded. Given that ERAS protocols are de-signed to address several factors related to perioperative patient care, we did not include studies examining the ef-fect of single variables on outcomes in the absence of an enhanced-recovery framework. A flow diagram detailing methods for selection of studies is presented in Fig. 2. Sur-veyed outcomes were LOS and rates of readmissions and complications. Data from the included studies were inde-pendently extracted by the first author.

Search terms for spine surgery: “spine,” “spinal,” “lum-bar,” “cervical,” “decompression,” “discectomy,” “diske-ctomy,” “laminectomy,” “laminotomy,” “foraminotomy,” “facetectomy,” “spondylolisthesis,” “scoliosis,” “kypho-plasty,” “vertebroplasty,” “laminoplasty,” “TLIF,” “PLIF,” “ALIF,” “LLIF,” “XLIF,” “OLIF,” “Smith-Petersen os-teotomy,” “Smith Petersen osteotomy,” “Smith-Peterson osteotomy,” “Smith Peterson osteotomy,” “Ponte osteoto-my,” “pedicle subtraction osteotomy,” “vertebral column resection,” “anterior column realignment.” Search terms for ERAS: “fast track,” “fast-track,” “ERAS,” “enhanced recovery protocol,” “enhanced recovery pathway,” “en-hanced recovery program,” “enhanced recovery system,” “enhanced recovery strategy,” “enhanced recovery after surgery,” “clinical pathway,” “critical pathway,” “multi-

modal perioperative,” “perioperative protocol,” “postop-erative protocol,” “postoperative recovery,” “accelerated recovery,” “recovery program,” “recovery pathway,” “mul-timodal postoperative.”

ResultsAs enhanced-recovery programs are not currently

widely adopted within spine surgery, many investigational studies report their initial approaches to and results of in-troducing such programs. We categorized these studies as surgery in the lumbar spine, surgeries for correction of scoliosis or deformity, and surgeries of the cervical spine. Combined cervical/lumbar cohorts were included under cervical surgery.

Lumbar SpineSoffin et al.46 designed an enhanced-recovery path-

way for 61 patients undergoing lumbar microdiscectomy or decompression surgery. Preoperative elements of their protocol included patient education, limited fasting, and a carbohydrate beverage 4 hours prior to surgery. Adjunc-tive nonopioid analgesics and antiemetic prophylaxis were provided. Intravenous fluids and warming were targeted to maintain euvolemia and normothermia. A minimally invasive approach to both surgeries was utilized. Foley

FIG. 2. Flow diagram showing study selection process.


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catheters and drains were avoided. Other components of postoperative management included cessation of intrave-nous fluids, prompt oral intake, and rapid mobilization. They reported a median LOS of 279 minutes overall. No readmissions within 3 months of surgery were seen.

Wang et al.54 proposed an ERAS protocol for 42 pa-tients undergoing lumbar fusion. They did not implement pre- and postoperative elements of the pathway but rather focused on the operative approach and anesthetic consid-erations. The procedure consisted of a minimally invasive transforaminal lumbar interbody fusion (TLIF) via an en-doscopic channel with percutaneous pedicle screw fixation and was performed entirely under conscious sedation and with application of local anesthetic agents. In their series, laryngeal access was not obtained. Foley catheters were not placed, and narcotic medications were not utilized. They reported no intraoperative events related to anesthe-sia, sedation, or medical events. All patients were ambula-tory on either the day of or the day after surgery. A follow-up study by Wang et al.53 retrospectively compared the first 38 patients treated with their ERAS protocol to a group of 15 patients who underwent minimally invasive TLIF prior to the introduction of the enhanced-recovery se-quence. Differences between the two groups included the use of general anesthesia and surgery without utilization of the endoscope or the addition of liposomal bupivacaine in the comparison group. Shorter LOS (1.23 vs 3.9 days, p = 0.009), reduced operative time, less blood loss, fewer complications, and a 15.2% lower total cost for acute-care hospitalization were observed in the ERAS group.

Although not utilized by them in this series, Wang et al.54 provided recommendations regarding other peri-operative components of a complete enhanced-recovery pathway, including patient education; nutrition; carbohy-drate loading; avoiding routine use of drains and urinary catheterization; targeting euvolemia, normothermia, and normotension; and early postoperative mobilization and enteral nutrition.

Grasu et al.20 retrospectively evaluated the efficacy of an enhanced recovery after spine surgery (ERSS) program in 56 patients who underwent spine surgery for metastatic tumors. A variety of open and minimally invasive proce-dures were utilized. Their pathway included preoperative education and multimodal management of pain and anxi-ety, carbohydrate loading with limited fasting, euvolemia, normothermia, utilization of minimally invasive tech-niques when possible, and other elements. Postoperatively, emphasis was placed on early ambulation, rehabilitation, and oral intake. Compared to 41 patients in the preprotocol cohort, those in the ERSS group achieved slightly better average pain control. However, no significant differences were seen with regard to 30-day readmission rates, com-plications, and LOS (6.3 vs 6.8 days, p = 0.590). The au-thors noted that patients with advanced metastatic disease or terminal illness may have prolonged hospitalizations for cancer care unrelated to surgical procedures for which they were admitted.

Nazarenko et al.36 applied a fast-track program to 23 patients who underwent microdiscectomy for lumbosa-cral disc herniation and compared results to 25 patients undergoing the same procedure managed with a standard

perioperative algorithm. Central aspects of their fast-track approach were presurgical optimization, patient education emphasizing the patient’s role in rehabilitation, early phys-iotherapy, and goal-directed discharge. Patients in the fast-track group had a faster recovery and significantly shorter LOS (2.3 vs 3.8 days, p < 0.05). Furthermore, patient satis-faction questionnaires revealed improved pain control and improved overall patient experience in the fast-track group.

Scanlon and Richards43 instituted early ambulation and enteral nutrition and optimized anesthetic agents to achieve faster return to baseline in 27 patients undergo-ing lumbar decompression. Using such a program, they reported same-day discharge without increased 30-day re-admissions. Although not including a formal control group in the study design, the investigators reported that patients undergoing this surgery at their institution had historically been admitted for 1–3 days postoperatively.

Fleege et al.14 described a fast-track protocol for patients undergoing one- to two-segment stabilization for degen-erative lumbar spine pathologies. By ensuring patient edu-cation, mobilization on the day of surgery, and aggressive rehabilitation, the investigators were able to reduce hospi-tal LOS from 10.9 to 6.2 days.

Zhang et al.56 explored the feasibility of enhanced re-covery after surgery in patients with lumbar spondylolis-thesis undergoing mobile microendoscopic discectomy and TLIF. They found that the ERAS pathway reduced intraoperative bleeding, shortened LOS, improved postop-erative pain, and promoted rapid rehabilitation of patients without impacting long-term outcomes.

Bradywood et al.6 implemented a care pathway for pa-tients undergoing lumbar fusion. They hypothesized that variation in postoperative management was a significant cause of inefficiency in their healthcare system and cre-ated a protocol to address pain control, time points at which to discontinue patient-controlled analgesia (PCA) and Foley catheters, frequency of mobility, and communi-cation between healthcare teams, among other factors. In their analysis of 458 patients, they found that the clinical care pathway decreased mean LOS from 3.9 to 3.4 days (p < 0.001), resulted in a more favorable disposition (75% vs 64% discharged to home, p = 0.002), and significantly reduced duration of urinary catheterization compared to historical controls. No changes were seen in 30-day read-missions or patient satisfaction data.

Correction of Scoliosis and Spinal DeformityA clinical pathway by Muhly et al.35 incorporated mul-

timodal analgesia, early mobilization, prompt discontinu-ation of opioid medications, and other measures for rapid recovery in adolescents undergoing posterior spinal fusion (PSF) for idiopathic scoliosis. Study groups included his-torical controls (n = 134), patients from a transition period when the program was introduced and modified (n = 104), and patients in the rapid-recovery pathway (n = 84). A de-crease in the mean LOS from 5.7 to 4 days and reduced pain scores on postoperative days 0 and 1 were observed after transition into and full implantation of the rapid-re-covery pathway. Similar rates of 30-day readmissions were observed.

Gornitzky et al.19 compared 58 patients undergoing a


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rapid-recovery pathway after PSF for adolescent idiopathic scoliosis (AIS) to 81 historical controls. Similar to Muhly et al.,35 they instituted early rehabilitation, transition to oral intake, and prompt discontinuation of drains, catheters, and opioid analgesics. The results showed significantly faster time to urinary catheter removal (1.5 vs 2.0 days) and PCA discontinuation (2.0 vs 3.6 days) and a shorter LOS (3.5 vs 5.0 days) (p < 0.001 for all comparisons). Mean daily pain scores were significantly reduced on postoperative days 0, 1, and 2. There was no difference in 30-day readmission rates between the groups.

Chan et al.8 examined the feasibility and outcome of an accelerated recovery protocol in 74 adolescents undergoing PSF for correction of idiopathic scoliosis. Fixed discharge criteria were set, and postoperative recovery milestones were established to address the removal of urinary cath-eters and subfascial drains, as well as timing of dressing changes, mobilization, and PCA discontinuation. Methods to improve postoperative pain management, shorten op-erative time, and minimize blood loss were implemented. Intraoperative antiemetic prophylaxis was provided. Com-pared to 33 historical controls, the enhanced-recovery group had a shorter mean LOS (5.2 vs 3.6 days). Only 1 patient failed to meet milestones, and the only complica-tion was a superficial wound infection in 1 patient that was managed on an outpatient basis. No other complications or readmissions were seen within the 4-month follow-up period.

Fletcher et al.15 evaluated the efficacy of an accelerated discharge (AD) pathway for patients undergoing PSF for AIS. They compared the AD protocol at one center to a traditional discharge (TD) pathway at a different center. The pathway emphasized early transition to oral pain medications, frequent mobilization with physical thera-py, and discharge regardless of a return of bowel function. One hundred five patients were treated by an AD pathway, whereas 45 patients were managed using a TD pathway. The AD group had a 48% shorter LOS (2.2 vs 4.2 days, p < 0.0001) and significantly fewer total complications than the TD cohort. There was no difference in readmission rates between groups. In their earlier work studying patients with AIS undergoing PSF, Fletcher et al.16 compared 279 patients managed with an AD pathway at one institution to 86 patients treated with a standard discharge pathway at a separate institution. Their results demonstrated that an AD pathway prioritizing early transition to oral pain medica-tions and a solid diet, frequent mobilization with physical therapy, and early removal of drains and urinary catheters resulted in earlier discharge (2.9 vs 4.3 days, p < 0.0001) and no significant increase in complications.

Sanders et al.42 tested an AD pathway for the man-agement of AIS in 90 patients compared to 194 patients managed with a TD pathway. Their pathway incorporat-ed similar measures to those described by Fletcher et al. Shorter mean durations of hospitalization were seen when comparing the two groups (3.7 vs 5.0 days, p < 0.001). Inci-dence of complications or readmissions was not increased in the AD group. Hospital charges for postoperative care were 22% lower ($18,360 vs $23,640, p < 0.0001) in the AD cohort compared to the TD group.

Rao et al.40 conducted a retrospective review of adoles-

cents who had undergone PSF before and after implemen-tation of pathways to standardize aspects of postoperative care such as pain, management of incisions, nutrition, void-ing, and activity. A later revision to the protocol required removal of the Foley and epidural catheters a day earlier. Data were gathered for 51 patients managed before intro-duction of any protocols, 100 patients who were managed with the first protocol, and 39 patients managed with the second protocol. Clearance for discharge by physical ther-apy, time to removal of Foley catheter and epidural/PCA, and LOS were significantly decreased in patients managed with the final protocol.

Cervical and Combined Cervical/Lumbar CohortsSivaganesan et al.44 performed a retrospective analy-

sis comparing patients who underwent elective lumbar or cervical spine surgery before and after implementation of an ERAS protocol (n = 1579 and 151 for preprotocol and postprotocol, respectively). Procedures included anterior cervical discectomy and fusion (ACDF), microdiscecto-my, and laminectomy with or without fusion. Elements of the protocol included appropriate thromboembolism prophylaxis, use of bracing when indicated, bed rest in case of durotomy, multimodal pre- and postoperative pain control, and suitable antibiotic prophylaxis. Early patient mobilization, drain removal, and discharge planning were emphasized. Results demonstrated reduced LOS and 90-day complication rates for postprotocol patients. Discharge status, readmission rates, and 3-month patient-reported outcomes were comparable between the two groups. Sub-group analysis demonstrated no significant difference be-tween any outcome measures in patients undergoing cervi-cal surgery, while patients undergoing lumbar surgery in the ERAS pathway had a significantly shorter LOS (2.9 vs 2.5 days, p = 0.021) and fewer complications (12.8% vs 3.8%, p = 0.002).

Dai et al.11 instituted an ERAS protocol for 35 patients undergoing ACDF and laminoplasty for cervical spondy-lotic myelopathy. Compared to a control group of 20 pa-tients, the ERAS group had a significantly shorter average LOS (5.62 vs 9.85 days, p < 0.01). Additionally, short-term (≤ 30 day) visual analog scale and Japanese Orthopaedic Association scores were significantly improved in the ERAS cohort.

Venkata and van Dellen50 described the implementa-tion of an enhanced-recovery program utilizing extensive patient counseling, preemptive coordination of disposition needs, limitation of opioid medications, emphasis on early mobilization, and avoidance of drains and blood transfu-sions in patients undergoing open surgery for degenerative lumbar (n = 187) and cervical (n = 50) conditions. The in-vestigators successfully achieved same-day discharge for many patients with few readmissions within 30 days and no long-term complications.

DiscussionThe majority of reviewed studies found that implemen-

tation of enhanced-recovery protocols in spine surgery was feasible and associated with a shorter LOS and ac-celerated return to function without increasing rates of


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complications or readmissions. This benefit was observed across several procedures and patient cohorts. Common el-ements seen in many enhanced-recovery pathways are the utilization of minimally invasive surgery when possible, use of multimodal analgesia, and early rehabilitation and enteral nutrition.

The use of minimally invasive approaches is increas-ingly common in spine surgery.24 Several of the reviewed studies incorporated these techniques as part of their en-hanced-recovery pathways. Numerous systematic reviews and meta-analyses18,34,39 have found minimally invasive spine surgeries to be associated with shorter LOS, while having comparable long-term outcomes. Nevertheless, surgical planning must consider other variables besides recovery time and ultimately is to be decided on a case-by-case basis.

Although several of the aforementioned ERAS proto-cols differed in the exact analgesic regimen, multimodal pain control was a common theme. In their article on perioperative principles related to complex spine surgery, Lamperti et al.27 listed and reviewed evidence surrounding several nonopioid medications that may be utilized to de-crease postoperative pain. Given the extensive side effect profile of opioid medications, the use of adjunct analgesics whenever possible is encouraged.

There is evidence that early oral intake after surgery is safe and may hasten return of bowel function and re-duce the duration of hospitalization in other surgical disciplines.9,17,23,37,55 While evidence targeted specifically at spine surgery is lacking, acceleration of postoperative enteral nutrition was a cornerstone of many of the afore-mentioned enhanced-recovery programs and is routinely incorporated in ERAS pathways in other surgical fields.33

The benefits of early mobilization following spine sur-gery and other procedures were reviewed by Epstein.12 Many studies revealed reduced rates of infections and medical complications along with decreased average LOS after instituting early-mobilization protocols. In addition to hastening a return to baseline level of function, acceler-ated ambulation and rehabilitation also serve to emphasize the patient’s role in recovery.

The majority of studies we found examined the ben-efits of ERAS for degenerative disease and stenosis of the lumbar spine. While these are certainly among the most commonly encountered pathologies, we especially note a lack of investigations addressing adults undergoing recon-struction for spinal deformity and degenerative scoliosis. This is an important area of further research given the rising frequency of and tremendous costs associated with correction of adult spinal deformity.58 Lastly, no studies addressed intradural lesions of the spinal cord itself; these surgeries may also be amenable to the application of en-hanced-recovery principles.

Despite the increasing rates of spine procedures,26 stan-dardized criteria for perioperative management for specif-ic surgeries are lacking. This variation in practice may be a cause of extended hospitalizations in patients undergoing lumbar and cervical spine surgeries.1,2 Given their nature as evidence-based platforms intended to streamline care and reduce waste, enhanced-recovery strategies enforce the use of standardized principles to minimize variations

in practice among surgical teams. Enforcing consistency of postoperative care may underlie some of the benefit im-parted by the adoption of ERAS programs.

There are limitations to the reviewed data and our study that should be noted. As there is no technical definition for an ERAS protocol, there is a risk of bias at the reporting level when deciding which studies to include. A quantita-tive synthesis was not performed due to heterogeneity in the reviewed studies with regard to design, populations, procedures, methods, and outcomes. Not all studies had formal control groups. Some outcomes, such as pain con-trol and cost, were not reported across all studies. We therefore focused on outcomes that were most likely to be consistently reported. Lastly, many studies compared rates of complications between intervention and control groups; however, the exact definition of this outcome var-ied among studies.

ConclusionsCurrent evidence surrounding the use of ERAS pro-

tocols in spine surgery is largely restricted to retrospec-tive reviews of nonrandomized data sets and preliminary cohort studies lacking formal control groups. These in-troductory studies have demonstrated the potential of enhanced-recovery protocols to reduce LOS, acceler-ate return of function, minimize postoperative pain, and save costs. Rigorous RCTs may serve to provide robust evidence and establish the efficacy of enhanced-recovery programs for particular patient populations and proce-dures within spine surgery. Indeed, Ali et al.3 provided a detailed protocol for a future multicenter RCT to test improvements in healthcare quality associated with im-plementation of an ERAS pathway in patients undergo-ing elective spine surgeries. Given the nature of ERAS programs as quality improvement initiatives, continuous data-driven reassessment and optimization are integral to ensure excellent outcomes.

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DisclosuresThe authors report no conflict of interest concerning the materi-als or methods used in this study or the findings specified in this paper.

Author ContributionsConception and design: Elsarrag, Soldozy. Acquisition of data: Elsarrag. Analysis and interpretation of data: Elsarrag, Patel. Drafting the article: Elsarrag, Soldozy, Patel. Critically revising the article: Kalani, Elsarrag, Soldozy, Patel. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Kalani. Administrative/technical/material support: Kalani, Norat, Sokolowski, Park, Tvr-dik. Study supervision: Kalani, Norat, Sokolowski, Park, Tvrdik.

CorrespondenceM. Yashar S. Kalani: University of Virginia Health System, Char-lottesville, VA. [email protected].


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